Oncology cases2021.docx

Case (1) BRAJFEC
A 48-year-old female in good health, recently diagnosed with breast cancer. The
pathology report indicates: invasive lobular carcinoma, high risk, Grade 3, tumor
size 2.5 cm, no lymphovascular invasion (0/11 lymph nodes involved), estrogen
and progesterone receptor positive (3+/3+), HER2 negative.
She has had a mastectomy and is scheduled for chemotherapy treatment.
She arrives at the hospital in preparation for treatment. She had baseline blood
tests performed at an outside lab 1 week ago, as follows:
WBC 5.3 Bilirubin 1.2 LDH 409
ANC 4 Creatinine 1.0
Hgb 12 Alk Phos 93
Platelets 320 AST 35
Pharmacy received a written order on a BRAJFEC pre-printed order sheet
Height: (165.1 cm)
Weight: (59.1 kg)
1-Calculate BSA and chemotherapy doses.
BSA= 1.65 m2
Chemotherapy doses:
Epirubicin
100mg/m2*BSA= 100×1.65= 165 mg/m2
Fluorouracil
500mg/m2*BSA= 500×1.65= 825 mg/m2
Cyclophosphamide
500mg/m2*BSA= 500×1.646= 825 mg/m2
Case(2) BRAVDOC
Four years later, This patient now 52 years old, returns complaining of bone pain
and shortness of breath. A diagnosis of metastatic disease with pulmonary and
osseous involvement is confirmed by CT and bone scan.
She is scheduled to receive cancer drug treatment with the BRAVDOC protocol
Lab work –(1 week prior to first cycle of treatment)

WBC 7 Bilirubin 1.0
ANC 3.9 Alk Phos 69
Hgb 12.8 ALT 24
Platelets 216 AST 30
Written orders received on a BC Cancer preprinted order.
Now her weight 52.3kg height 165cm
1-Calculate BSA and chemotherapy doses.

BSA= 1.55 m2
Chemotherapy doses:
DOCEtaxel
100mg/m2*BSA= 100×1.548= 155 mg/m2
2-What is the precaution for administration of this protocol and supportive

care medication.
1. Fluid retention: Dexamethasone premedication must be given to reduce

incidence and severity of fluid retention.
2. Hypersensitivity: Reactions are common but it is not necessary to routinely
initiate the infusion slowly. If slow initiation of infusion is needed, start infusion at
30 mL/h x 5 minutes, then 60 mL/h x 5 minutes, then 120 mL/h x 5 minutes, then
complete infusion at 250 mL/h (for 500 mL bag, continue 250 mL/h for 5 minutes
and then complete infusion at 500 mL/h).
3. Extravasation: Pain and tissue necrosis.
4. Neutropenia: Fever or other evidence of infection must be assessed promptly
and
treated aggressively.
5. Hepatic Dysfunction: DOCEtaxel undergoes hepatic metabolism. Hepatic
dysfunction (particularly elevated AST or ALT) may lead to increased toxicity and
usually requires a dose reduction. Baseline liver enzymes are recommended
before
cycle 1 and then if clinically indicated (eg, repeat liver enzymes prior to each
treatment if liver enzymes are elevated, liver metastases are present or there is
severe toxicity such as neutropenia). If liver enzymes are normal and there is no
evidence of liver metastases or severe toxicity, check liver enzymes after 3
cycles
(ie, at cycle 4).
Case(3): GIFOLFOX
A 43-year-old female, diagnosed with carcinoma of the sigmoid colon, previously
treated with surgery and post-op chemotherapy (12 cycles of GIAJFL) completed
in August of the previous year. She returns to clinic, now diagnosed with
metastatic disease (hepatic involvement) and is scheduled for treatment with
GIFOLFOX
Baseline blood tests were performed at an outside lab 3 weeks ago. Lab results
–
WBC 13.7 Creatinine 0.9 Electrolytes WNL*
ANC 1.7 Bilirubin 0.4 Ca, Mg WNL
Hgb 12.4 AST 40
Platelets 495 Alk Phos 203
height 150 cm, weight 55 kg,
Calculate the dose and administration guidelines for this protocol?
BSA= 1.51 mg/m2

Chemotherapy doses:
Oxaliplatin
85mg/m2*BSA= 85×1.51= 128.68 mg/m2
Administration Guidelines: IV in 250 to 500 mL of D5W over 2 hours
Leucovorin
400mg/m2*BSA= 400×1.51= 604 mg/m2
Administration Guidelines: IV in 250 ml D5W over 2 hours
Fluorouracil
400mg/m2*BSA= 400×1.51= 604 mg/m2
Administration Guidelines: IV push, after Leucovorin, THEN
Fluorouracil
2400mg/m2*BSA= 2400×1.51= 3624 mg/m2
IV over 46 h in D5W to a total volume of 230 mL by continuous
infusion at 5 mL/h via Baxter LV5 INFUSOR
Case 4: Nausea/Vomiting and Altered Mental Status in a Patient with Metastatic

NSCLC (oncological emergency)
A 65-year-old female with metastatic non-small cell lung cancer (NSCLC) of squamous
cell histology presents with nausea/vomiting and changes in mental status. She is on day
8 gemcitabine.
History: Seven days ago, the patient received cycle 2 of cisplatin and gemcitabine for her
NSCLC. The patient took antiemetics as directed, but noticed she had become
disoriented and confused over the last 2 days. She is still taking her antiemetic
prochlorperazine every 4 hours with minimal relief.
Her medical history includes hypertension and Stage IV NSCLC with bone metastasis.
She was taking the following medications: hydrochlorothiazide 25mg daily,
prochlorperazine 10mg every 4 hours as needed for nausea/vomiting, dexamethasone
8mg daily for 3 days post-chemotherapy, and aprepitant 80mg daily for 2 days post-
chemotherapy.
Her laboratory test results were as follows:
Na 140mEq/L WBC 4.5
K 3.4mEq/L Hgb 12g/dL
CL 110mEq/L Plts 140
Albumin 2.4g/dL BUN 48mg/dL
Scr 1.6mg/dL Ca 16mg/dL
What is the likely cause of the patient’s nausea/vomiting and mental status changes?
What is the management of this condition?
Case5:
28 years old man receiving high dose methotrexate as part of multidrug regimen for
osteosarcoma while receiving chemotherapy his serum creatinine rises from0.8 to
2.1mg\dl at the last 3 days
What is the likely diagnosis?
-Crystal-induced nephropathy
What measures should the patient receive while treated with high dose methotrexate
-Hyperhydration and urine alkalinization are mandatory during HDMTX treatment
Case6: A 45 years old female presented 10 days after her second cycle of adjuvant AC
protocol with fatigue. Laboratory findings showed WBC 600/mm, neutrophil is 60%, band
neutrophil is 10%, monocytes 12%, basophils 8%and eosinophil 10%. She is afebrile and
hemodynamically stable.
Questions:
•What is her ANC?

ANC: 0.42 x 10 cells/L
Interpretation: Severe Neutropenia
•Would she need antibiotics?
No, as the patient is afebrile
•Would you recommend starting G-CSF right now?
Yes, as intervention with prophylactic G-CSF and/or antibiotic can prevent life-
threatening infections from setting in.
•For her next cycle would you start prophylactic G-CSF or reduce the dose of her
chemotherapy?
Give prophylactic G-CSF to prevent febrile neutropenia.
Case7: A patient received her fourth cycle of chemotherapy with paclitaxel-

carboplatin for ovarian cancer 12 days ago. She reports to the clinic today with a
temperature this morning of 103°F. Her CBC is WBC 5 × 102 cells/ mm3; segmented
neutrophils 55%; band neutrophils 5%; basophils 15%; eosinophils 5%; monocytes 15%;
and platelet count 99,000/mm3. She denies any signs and symptoms of infection. Her
blood pressure (BP) is 115/60 mm Hg; heart rate is 80 beats/minute; and respiratory rate
is 15 breaths/minute.
Which best represents the patient’s absolute neutrophil count (ANC)?

A. 275.
B. 300.
C. 25.
D. 500.
Which is the best course of action for the patient in the previous question?
A. Admit to the hospital for intravenous antibiotic drugs.
B. Treat as an outpatient with antibiotic drugs.
C. Initiate a colony-stimulating factor (CSF).
D. Discontinue chemotherapy.
Case 8: K.L. is a 50-year-old female with metastatic pancreatic carcinoma; her

performance status is ECOG 2. She has been receiving gemcitabine with palliative intent
using the GIPGEM protocol. She returns to the clinic to see her oncologist today
(October 21).
Her weight on September 3 was 50 kg.
Today’s weight: 46.5 kg Height: 139 cm
Gemcitabine treatment history: Gemcitabine 1400 mg on September 3, 10, 17,
24, October 1, 8 and 15.
Lab results – October 21
WBC 4.7
ANC 2.7
Hgb 10.8
Platelets 257
Creatinine 1.2
What is the patient’s current BSA, using the Mosteller equation?

1.43 m2
1.34 m2
1.38 m2
1.31 m2
The physician has prescribed 1400 mg IV gemcitabine to be given on October 22.

Are the dose and interval of treatment appropriate?
1. Yes, both the dose and interval are correct.
2. No, both the dose and interval are incorrect. The dose should be 1340 mg
and she should be scheduled for treatment on October 29.
3. No, the dose is incorrect but the interval is correct. The dose should be
1340 mg.
4. No, the dose is correct but the interval is incorrect.
- She should be scheduled for treatment on October 29.
K.L.’s ANC = 0.9 and platelets = 180 on the day she is due to start Cycle 3, Week 1.
How would these lab results affect the dose for Cycle 3?
1. There would be no change.
2. Her dose should be delayed to allow her counts to recover.
3. Her dose should be reduced to 1050 mg.
4. It is a clinical decision. The oncologist might choose to reduce her dose to
1050 mg or delay treatment.
Based on the protocol, how long should K.L. continue treatment?

1. Continue treatment as long as there is evidence of a clinical response,
usually a partial response or stable disease associated with symptom
improvement (decreased pain, weight gain, improved performance status),
or until there is unacceptable toxicity.
2. Continue treatment for 6 cycles; if there is no improvement after 6 cycles,
consider an alternative protocol.
3. Continue treatment for 8 cycles; if there is no improvement after 8 cycles,
consider an alternative protocol.
4. Discontinue gemcitabine, as disease progression is a sign that the tumour is
unresponsive to therapy.
Case9:
J.P. is a 57-year-old male, diagnosed with extensive small cell lung cancer. The
treatment plan is for him to start on the LUSCPE protocol.Lab results taken 24 hours
prior to first treatment:
• WBC 8.4
• ANC 6.2
• Hgb 149
• Platelets 149
• Weight: 87 kg Height: 160 cm
•
What is the patient’s BSA, using the Mosteller equation?
1. 1.97 m2
2. 1.9 m2
3. 1.96 m2
4. 2 m2
Given the calculated BSA, what should the dosing regimen be?
1. 49 mg CISplatin IV and 197 mg etoposide IV daily × 3 days
Based on the protocol, when should J.P. receive his second cycle of chemotherapy?
1. In one week
2. In two weeks
3. In three weeks
4. In four weeks
What are the minimum hematologic lab values J.P. would have to exhibit to continue
with his current dose of etoposide?
1. ANC greater than 1.5 and platelets greater than 100
2. ANC less than 1.5 and platelets less than 100
3. ANC greater than 1.0 and platelets greater than 75
4. ANC = 1.5 and platelets = 100

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Case (1) BRAJFEC

Lab work –(1 week prior to first cycle of treatment)

1-Calculate BSA and chemotherapy doses.

2-What is the precaution for administration of this protocol and supportive

1. Fluid retention: Dexamethasone premedication must be given to reduce

Calculate the dose and administration guidelines for this protocol?

BSA= 1.51 mg/m2

Case 4: Nausea/Vomiting and Altered Mental Status in a Patient with Metastatic

Na 140mEq/L WBC 4.5

K 3.4mEq/L Hgb 12g/dL

CL 110mEq/L Plts 140

Albumin 2.4g/dL BUN 48mg/dL

Scr 1.6mg/dL Ca 16mg/dL

•What is her ANC?

Case7: A patient received her fourth cycle of chemotherapy with paclitaxel-

Which best represents the patient’s absolute neutrophil count (ANC)?

Case 8: K.L. is a 50-year-old female with metastatic pancreatic carcinoma; her

What is the patient’s current BSA, using the Mosteller equation?

The physician has prescribed 1400 mg IV gemcitabine to be given on October 22.

Based on the protocol, how long should K.L. continue treatment?

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